Pilot Debrief

BEECH C23 near Ludlow, CA — 2019-06-30

Final reportWPR19LA187
Sign in to save
Date
2019-06-30
Location
Ludlow, CA, USA
Aircraft
BEECH C23
Registration
N24580
Category
Airplane
Highest injury
None
Fatalities
0
Phase of flight
Cruise

Probable cause

Maintenance personnel’s failure to properly tighten an oil line fitting, which resulted in a total loss of engine power.

NTSB narrative

The pilot and the passenger departed on a cross-country flight. While at cruise, the pilot noted a faint smell of burning paint, followed by the oil pressure drop to zero and eventually experienced a complete loss of engine power. The pilot performed an emergency landing during which the airplane sustained substantial damage. A postaccident examination revealed there was no oil remaining in the engine, the AN hose fitting on the oil cooler was loose, and there was evidence of an oil leak in the area of the loose fitting. No other pre-impact mechanical anomalies were detected that could have precluded normal operations. The engine had been overhauled about 4 operating hours prior to the accident. The accident is consistent with maintenance personnel failing to properly tighten the oil hose fitting, which resulted in a total loss of engine power.

Analysis

Primary failure mode
Engine power loss
First missed decision gate
Pilot could have checked oil levels more thoroughly before flight.

NTSB coding

Evidence available

  • Video
  • Photos
  • 6 docket documents
View NTSB final reportView NTSB docket

Docket documents6

Related mishaps